Infection Preventionist Lacks Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist had completed the required specialized training in infection prevention and control. This deficiency was identified during a recertification survey conducted from December 2, 2024, to December 9, 2024. The review of the Infection Control Task revealed that the Infection Preventionist, who had been in the role since early 2023, did not have documented evidence of completing the necessary specialized training. The facility's job description for the Infection Preventionist clearly stated that the candidate must have completed such training, yet the only documentation provided was a certificate in Infection Control and Barrier Precautions with four contact hours dated February 28, 2023, which did not meet the specialized training requirement. Interviews conducted during the survey further highlighted the lack of awareness regarding the training requirement among the facility's leadership. The Infection Preventionist, Director of Nursing, and Administrator all stated they were unaware of the specialized training requirement for the role. The Infection Preventionist assumed the position without the necessary training, and the Director of Nursing and Administrator were not informed of this requirement, leading to the deficiency in the facility's infection prevention and control program.
Plan Of Correction
Plan of Correction: Approved January 7, 2025 Immediate Corrective Action: - Assistant DON (Infection Preventionist) successfully completed the specialized training in infection prevention on 12/03/24. - In addition, we will continue the support of The Infection Control Preventionist from our Nurse Practitioner who provides additional onsite support. - DON and Assistant DON was re-educated on the Infection Preventionist policy and procedure. Identification of Others Potentially Affected: - The facility respectfully submits all residents were potentially affected by this practice. System Changes to Prevent Recurrence: - Compliance Officer reviewed and revised the Infection Preventionist job description and policy and procedure on 12/05/24. - DON, ADON and NP were in-serviced on the revised job description and policy and procedure on 12/10/24. - ADON and Nurse Practitioner will actively participate in IPRO QIN QIO that offers free access to AHCA/NCAL’s Infection Preventionist Specialized Training (IPCO). - Audit tool has been created and put into place for ongoing compliance monitoring. Quality Assurance Monitoring: - Infection Preventionist is a member of the facility’s QAA Committee. The Infection Preventionist routinely report to the QAA Committee on the facility’s IPCP. - Audit tool has been created and put into place for ongoing compliance monitoring. - The Director of Nursing will conduct auditing and monitoring to ensure surveillance and monitoring of active infections in the facility is being implemented, and the ADON (Infection Preventionist) is receiving specialized education and training. After 4 weeks of weekly monitoring and demonstrating that expectations are being met, monitoring will reduce to twice monthly for one month. Monthly monitoring will continue at a minimum for 2 months. Responsible Party: - Assistant DON and Nurse Practitioner